How the Affordable Care Act and Medicaid Are Connected (But Not the Same)

The Affordable Care Act and Medicaid are separate programs, but the ACA expanded Medicaid in many states

The Affordable Care Act (ACA), often called Obamacare, is a federal law passed in 2010 that changed how health insurance works in the United States. Medicaid is a joint federal-state program that pays for health care for people with low incomes — it existed long before the ACA. The ACA did not rename Medicaid or turn it into one program. Instead, the law gave states the option to expand their Medicaid programs to cover more people, and many (but not all) states chose to do so.

Think of it this way: the ACA created new pathways to coverage, and one of those pathways was through an expanded Medicaid program. If you live in a state that expanded Medicaid, you may have become newly covered under Medicaid because of the ACA. But Medicaid itself is still the same program it always was — run by your state, with its own rules, income limits, and covered services.

Key Takeaways

• The ACA is a law that changed health insurance rules; Medicaid is a program that pays for health care for low-income people — they are not the same thing.
• The ACA gave states the choice to expand Medicaid to cover more people, and 38 states plus Washington, D.C. have chosen to do so as of 2024.
• If you got Medicaid coverage after 2014, you may have become covered because your state expanded Medicaid under the ACA, but you are still enrolled in your state's Medicaid program.
• Income limits and covered services differ by state, even among states that expanded Medicaid under the ACA.

What the ACA actually did to Medicaid

The ACA included a provision that allowed states to expand Medicaid to cover adults earning up to 138 percent of the federal poverty level. Before the ACA, Medicaid covered mainly children, pregnant people, parents, elderly people, and people with disabilities — not working-age adults without children. The expansion was meant to close that gap.

The federal government offered to pay 100 percent of the cost of newly covered people for the first three years (2014–2016), then gradually reduce that to 90 percent by 2020 and beyond. This made expansion financially attractive to states. However, a 2012 Supreme Court decision made expansion optional, not mandatory. Some states declined, and a few have still not expanded as of 2024.

In states that did expand, hundreds of thousands of people became newly covered under Medicaid. In states that did not expand, those same people often had no coverage option — they earned too much for the old Medicaid rules but too little to afford private insurance.

Which states expanded Medicaid, and what that means for you

As of 2024, 38 states plus Washington, D.C. have expanded Medicaid under the ACA. The remaining 12 states have not. Your state's choice affects whether you can get Medicaid coverage if you are a working-age adult without children or a disability.

If you live in an expansion state and your income is below 138 percent of the federal poverty level (roughly $20,000 per year for a single person in 2024, though this varies), you may be covered under your state's expanded Medicaid program. If you live in a non-expansion state, you would need to fit into one of the older categories — parent, child, pregnant person, elderly, or disabled — to get Medicaid, regardless of the ACA.

The non-expansion states are: Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, Tennessee, Texas, Wisconsin, Wyoming, and Maine (which expanded in 2024). Even within expansion states, income limits and the services covered can differ. Your state Medicaid office is the only source that can tell you whether you meet your state's specific rules.

How to learn about you are covered under your state's Medicaid program

Start by contacting your state Medicaid office directly. You can find the phone number and website through the Centers for Medicare & Medicaid Services (CMS) at medicaid.gov, which lists every state program. When you call, have your income information and household size ready.

You can also use Healthcare.gov, the federal marketplace created by the ACA, to see what coverage options are available to you based on your income and state. Healthcare.gov will tell you whether you appear to be covered under Medicaid in your state, and if so, it will direct you to your state Medicaid office to complete the process.

If you are already enrolled in Medicaid, your coverage letter or card will tell you which program you are in — it will say "Medicaid" or your state's specific program name (like "Medi-Cal" in California or "Badgercare" in Wisconsin). The ACA did not change the names of existing state programs; it just expanded who could join them.

The difference between Medicaid expansion and the ACA marketplace

The ACA created two main paths to coverage: Medicaid expansion (in participating states) and the health insurance marketplace, where you can buy private plans with federal tax credits if your income is between 100 and 400 percent of the federal poverty level. These are not the same thing.

If you live in a Medicaid expansion state and your income is below 138 percent of poverty, Medicaid is usually the first option because it costs nothing or very little. If your income is above that threshold, you would look at marketplace plans instead. If you live in a non-expansion state, Medicaid may not be an option for you at all, and the marketplace becomes your main route to coverage.

The ACA created both programs as part of the same law, which is why people sometimes confuse them. But they operate separately, with different income rules, different covered services, and different enrollment processes.

What happened to people who had Medicaid before the ACA

If you were already covered under Medicaid before 2014, the ACA did not change your coverage. You stayed in the same program under the same rules. The expansion added new people to Medicaid; it did not alter the existing program for people already enrolled.

However, some states have made changes to their Medicaid programs since the ACA passed — for example, adding new covered services or adjusting income limits. These changes vary by state and are not part of the ACA itself; they are decisions each state made separately. Your state Medicaid office can tell you what services are covered under your specific plan.

Frequently Asked Questions

Is Obamacare the same as Medicaid?

No. The Affordable Care Act (Obamacare) is a law that changed health insurance rules. Medicaid is a program that pays for health care. The ACA expanded Medicaid in some states, but Medicaid itself is a separate program that existed before the ACA and continues to operate under state rules.

If I got Medicaid after 2014, does that mean I have Obamacare?

You may have become covered under Medicaid because your state expanded the program under the ACA. But you are enrolled in Medicaid, not "Obamacare." The ACA is the law that made the expansion possible, but your actual coverage is through your state's Medicaid program.

What if my state did not expand Medicaid?

If your state did not expand Medicaid and you are a working-age adult without children or a disability, you likely cannot get Medicaid no matter what the ACA says. You would need to look at health insurance marketplace plans instead, where you may be able to get federal tax credits to lower your cost.

Can I switch from Medicaid to a marketplace plan?

Yes, but it is usually not the best choice. Medicaid is free or very low-cost, while marketplace plans require monthly payments. You would only switch if your income rose above your state's Medicaid limit, or if you wanted coverage that Medicaid does not offer in your state.

How do I know which Medicaid program I am in?

Your Medicaid card or coverage letter will show your program name. It may say "Medicaid" plus your state's name, or your state may use its own program name. Call the number on your card or contact your state Medicaid office if you are unsure which program covers you.